1. No category

Members Dresent
:
Dr.N.K Hazarika Medical Superintendent
Dr.Nilom Khound-Consuhant- Internal Medicine
Dr.Sushil Agarwal- Dy.Consultant-Psych iatry
Dr.Santanu Medhi- Dy.Consultant-Surgery
Mrs.Karabi Kalita-Legal Officer
Chairman
Members
The following dortor/recipient groups were evaluated.
st.
DONOR
RECIPIENT
RELATIONSHIP
1
Mrs.Ganga Sarma Das
Mr.Pranab Kumar Das
Spouse
2
Mrs.S.Kondmma
Mr.Veera Vadradu
Spouse
3
Mrs.Binapani Devi
4
Mrs.Agnoni Barman
Mr.Anil Kr Barman
Mother-Son
5
Mrs.Jharna
Purkayastha
Mrs.Moulinee
Purkayastha
Mother-Son
6
Mrs.Fatema Begum
Mrs.Sabina Yasmin
No.
Mrs.Himadri Sarma
Form 6 and Form 19 as defined at
rule
Mother-Daughter
S
isters
5(3) (c )and rule 2 (c) follows
:
(:r)
Form 6
For spousal living donor
(to be filled by comPetent authority+
case of foreigners)
a
nd Authorisation Committee, of the hospital or district or state in
lSee rule 18(2)
t,DrlMrlWslwiss...
'jlt'K' AAZ
DR
possessing qualification
Registered as medical practitioner at serial No
certify ^that
,AMt Y42A
of
-1413O
9
oy tne Araodnt- Medical council,
:
D/o
and
l-.b . -}pt
"
^c"i
o?t u e.0-
Are related to each other as spouse according to the
,tJ"."nt
resident
gir"n
ot--!&La^o!14%slt:€r
by them and
f_:*
'.&s
tdt'' *tttrn#t nt'
from the body of
Been confirmed bY means of following evidence before effecting the organ removal
a-(Urrrralf+ltApplicable only in the
the said Shri/Smt
cases where considered necessary)
OR
mentioned above is such that recording of
ln case the Clinical condition of Shri/Smt
(mention
his/her statement is not practicable, reliance will be placed on the documentary evidence(s)
documentary evidence(s here)
gr.6"uiag"
0
certificate indicate date of marriage
r
t'Ltl '+"
b'
Y'r
c
{t^"t
t
b. Marriage photogra Phs
with duration
c. Date when transplantation was advised by the hospital(to be compared
of
marriage)
d. Number and age of children and their birth certificates
e. Any other document
.-
-/*''n-' 1'ft*" *kI["^
/7', ; on rtJ
k^,at;k i]rs.
utho rity*/Authorisation committee in case of toreigners along with Seal/Stamp
j'Mrrr
n
pa-vt
Sisnature of competent
"
pyb
a
r'yt cz'G+'c'!'
u
v - *0
.--r/),^,
u'
7'vtt;.
'::;,ffi',6ob.Dp'|;
ptace:
Gtupq.rsri'
,
rY'i:::r::!i
(ffiiii-;L:l'
*Director or Medical superintendent or ln charge of the hospital or the internal committee of the
,n
a)
JD
Form 6
D.,'^'a'
For spousal living donor
*5
'
(to be filled by competent authority*and Authorisation Committee, of the hospital or district or state in
case of foreigners)
[See rule 18(2)
__)^809
Registered as medical practitioner at serial No
certify that :
,
Y
\Lq
Ou
4
,n" Agsal*
A1ao"o
Medicat councit,
turident of
-
D/o
33v ea-,
resident of
----T--Been confirmed by means of following evidence before effecting the organ removal from the body of
/1
(Applicable only in the cases where considered necessary)'
the said
shri/srft $' kDt'ld'D?'na
OR
mentioned above is such that recording of
ln case the Clinical condition of Shri/Smt
his/her statement is not practicable, reliance will be placed on the dOcumentary evidence(s) (mention
documenta ry evidence(s here)
l-afiarriage cerlificate indicate
date of marriage
b. Marriage photo8raphs
c. Date when transplantation was advised by the hospltal(to be compared with duration of
marriage)
d. Number and age of children and their birth certificates
e. Any other document
\,.- -{*--
''r'r'-\7-'" )lco*o-
\*vl*.
/;v^;Y\
{'"*'lu*',. wt-^w'<! wz\
Signature of competent
e\ace:
")
a
utho rity*/Atlthorisatio n committee in case of foreigners along with Seal/Stamp
et,,,nahali
lgllwlzotf
e!,"A!*1a4
.
'
-@=*^t|rffi:it^,
-*:"-lt"t'St$l;
rnt"ont;;;h"ti
*Director or Medical Superintendent or ln Charge of the hospital or the internal committee of the
FORM 19
Certificate by competent authority_[as defined at rule 2(c)] For lndian relative, other than spouse
Cases (ln case of spousal donor, Form 6 will be applicable )
See Rule 5(3) (c)
(Format for the decision of Concerned competent Authority
)
of Kidney from living donor who
is near relative under the Transplantation of Human Organs Act ,!994(42 of 1994) ,,submitted on
This is to certify that as per application in Form-11 for transplantation
llUln'
ov the donor and recipient, whose details and photographs are given below, along
interview of donor and recipient (if medically fit to be interviewed ) by the Competent
t?zlU )X-o t gAuthority in the meeting freta
on
Deta ils
of Dono r
Deta ils
of Recipient
Name
Name
71rs.
h.\alq-^ Dl.d
'
I
L\
Ase
age 'z^ YbfF,
W?3
"
l-Qr^'-t'L-
Arcr*-o,ae"
ru#riusaananame
+
Pl'r. c.L-frq
rather/H usba nK1"m"
o'l^v. ct^n;[-v'q
,aJ-/v\4-?.
W./?
'
^
.
Address:
Address:
cr",-tuY
G's. Dr--E
Hospital Reg.No
:
liLrr -
,
r:lun'^l'.--lolA
l*r,L
'*bqg'
^
- alg+lz
Relationship of Donor with Recipient
orni
Donor
&s'vi
(Photo of recipient and donor must be signed and stamped across the photo after affixing)
L,f6rmission is granted, asto the best of knowledge of the members of members of the committee,
donation is out of their being near relative and there is no financial transaction between recipient and
donor and there is no pressure/coercion on donor.
Permission is withheld pending submission of the following documents
Permission is not granted for the following reasons
na^
.L-.
.
r.>z-
/ du,*/
7-*'t'*
Wu'ucd
k"r"UW^f\
/'2
(Signature and stamp
Date and
of c
p1.." 13'
\^-^9
'fffi*i,ni,yt
0t+ Wt6 ,W'
FORM
"l
19
Certificate by competent authority-[as defined at rule 2(c)] For lndian relative, other than spouse
Cases (ln case of spousal donor, Form 6 will be appllcable )
See
le 5(3)(c)
Ru
(Format for the decision of Concerned Competent Authority
This is to certifi/ that as per application in Form-11 for transplantation
of
)
Kidney from living donor who
is near relative under the Trarisplantation of Human organs Act ,7994(47 ol L994) ,,submitted on
with their
by the donor and recipient, whose details and photographs are given below, along
itdentifications and verifications documents, the case was considered after the personal
interview of donor and recipient (if medically fit to be interviewed ) by the Competent
Authorlty in the meeting held
tAtu I za-(
on
{*
Deta ils
Details of Recipient
Na
of Donor
Name
me
Age
Ape br-, qw
Sex
Sex
p*f,erlnusband Name OlY.
li o-u
ratner/nusbhl-tl ane
Add ress:
Address:
l^t(.'
u;
lvl k)al W botu,
,t , 'nl-u4n , Da Dha*46Gt '
f\.-
vr'n bAu;LAA,
P,a, Dl'o^lobo
99 4-
Hospital Res.No I
Mqt - >> L q LLl
Hospital Reg.
,
Recipie r
Bqzaal
lluA-
Relationship of Donor with Recipient
L
LLlc{L-
)
Ac+nrr.?$.
Donor
fl*..cr^.,r.
(Photo of recipient and donor must be signed and stamped across the photo after affixing)
r-fermission is granted, asto the best of knowledge of the menrbers of members of the committee,
donation is out of their being near relative and there is no financial transaction between recipient and
donor and there is no pressure/coercion on donor.
ments
Permission is withheld pending submission of the following
q@M
*f
t,- t
^-' ,, tsl-/-'
,Z-y'cu'*'*n/
p. W,fot Xrtc Wtrd
5i.-{-f- '{-c, o L c-
o'*-D' U+
t
ohl^'^(
<tc."r&Ltr
J- d
'{}.fr'at btgn---C
) , 0or,lo, n* Q; c*a^
Permission is not granted for the following reasons
,,^
9
Werh"-
,i-.^o,o;L
(Sig natu
re and
Date and
FORM
-r
19
Certificate by competent authority-[as deflned at rule 2(c)] For lndian relative, other than spouse
Cases (ln case of spousal donor, Form 6 will be applicable )
See Rule 5{3) (cl
(Format for the decision of Concerned Competent Authority
This is to certiry that as per application in Form-1L for transplantation
of
)
Kidney from livinS donor who
is near relative under the Transplantation of Human Organs Act ,L994142 of 1994) ,,submitted on
by the donor and recipient, whose details and photographs are given below, along
with ttieir identifications and verifications documents, the case was considered after the personal
interview of donor and recipient (if medically fit to be interviewed ) by the Competent
Authority in the meeting held on
Deta ils
Details of Recipient
of Donor
Wr. sL-*--^ (^Ua+^*)
Name
*"^"
Age
Ase
9.> "{l-
Sex
Sex
F.,^-"-l-
Fat6r/Husband Name
W ^?. o gl"rilu,
rati{r/u
usba
nd Nane
(tv,
.
'?ro4,nJ+t
Add ress:
rto f,*"/l,L*l", D^j-/-y**D
Hospita I Reg.No
:
/ll9-'
2auto
t,tt-Yt-- /b3A
t4out-a- '
7.
Hospitalteg.
Relationship of Donor with Recipient
097
,
Q"(*l?{
Donor
Reciplent
(Photo of recipient and donor must be signed and stamped across the photo after affixing)
Lr€ffiission is granted, asto the best of knowledge of the members of members of the committee,
donation is out of their being near relative and there is no financial transaction between recipient and
donor and there is no pressu re/coe rcio n on donor.
Permission is withheld pending submission of the following documents
Permission is not Branted for the following reasons
- /*r.-
-257' ./l".o.r*'.r
7, - N
iloar Y'*'P ouad
V4+
e^-ruarv-lg
ry^,^b\Va!.t< t ..aAyy2
(
s
is
natu
re
a n
d
Dateand
st a m
p
"I 7.^:i(%r,n],,,r,
place
(6/
y4
,
o,,,nriYn
^u
^,
Certificatebycompetentauthority.[asdefinedatrule2(c)]Forlndianrelative,otherthanspouse
Cases (ln case of spousal donor, Form 6 will be applicable )
See Ru le 5{3)lc)
(Format for the decision of Concerned Competent Authority )
This is to certiry that as per application in Form-11 for transplantation
of
Kidney from living donor who
1994) ,,submitted
is near relative under the Transplantation of Human Organs Act ,1994(42 of
on
given below' along
the donor and recipient, whose details and photographs are
personal
;il. ,t/ld*,,1f'*tions and verifications documents, the case was considered after the
by the Competent
interview of donor and recipient (if medically fit to be interviewed )
tlUltll
nv
Authority in the meeting held
on /?l
O
Details of Donor
Details of ReciPient
L4>- h/b-
Ada
Fur*-S-'
Sex
rather/nusffi
ruame
lh ^ Nalzz(
'
ur'
Father/H usband Name
Address:
Address:
G l+a,.-*^-tu.aq, a4'6-1i44^d,
p0
-r6
*lor*rt b)^btv-fd\"'
P,
Hospital Reg.No:
RelationshiPof
wlw -
L03 b1>-
Hospital Reg.
uql.'
aJqoz?8,
Dc'-----.--
t_
I
Recipient
Donor
(Photo of recipient airo oonor must be signed and stamped across the photo after affixing)
l4€amission is granted, asto the best of knowledge of the members of members of the committee'
recipient and
donation is out of their beinB near relative and there is no financial transaction between
donor and there is no pressure/coercion on donor.
Permission is withheld pending submission of the following documents
Permission is not granted for the following reasons
J,\./ /
l*-
-,
-*\ /- '